Perioperative Management

  • Sean Joseph LangenfeldEmail author


Thoughtful perioperative management of the patient undergoing anorectal surgery is essential. This process starts with the detailed office evaluation of patient-reported symptoms, moves on to the decision to operate with a thorough preoperative assessment, and continues through the patient’s surgery and recovery. When correctly undertaken, patients can anticipate a safe and efficient surgery with appropriately minimized risks of morbidity and mortality. Areas of important focus in perioperative care include patient education, perioperative fluid restriction, and multi-modal postoperative pain control. Most anorectal surgery is performed in the ambulatory setting, which results in lower costs, a faster recovery, and high rates of patient satisfaction.


Ambulatory surgery Anorectal surgery Preoperative care Postoperative care Perioperative care Pain control Urinary retention Patient education Complications Pelvis sepsis 


  1. 1.
    Smith LE. Ambulatory surgery for anorectal diseases: an update. South Med J. 1986;79(2):163–6.CrossRefGoogle Scholar
  2. 2.
    Ternent CA, Fleming F, Welton ML, Buie WD, Steele S, Rafferty J. Clinical practice guidelines for ambulatory anorectal surgery. Dis Colon Rectum. 2015;58:915–22.CrossRefGoogle Scholar
  3. 3.
  4. 4.
    ASA physical status classification system, last approved by the ASA House of Delegates on October 15, 2014. Available at: Accessed 21 June 2018.
  5. 5.
    Apfelbaum JL, Connis RT, Nickinovich DG, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522–38.CrossRefGoogle Scholar
  6. 6.
    Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT. Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009;108:467–75.CrossRefGoogle Scholar
  7. 7.
    Czoski-Murray C, Lloyd Jones M, McCabe C, et al. What is the value of routinely testing full blood count, electrolytes, and urea, and pulmonary function tests before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: a systematic review of the clinical and cost-effective literature. Health Technol Assess. 2012;16:i–xvi,1.CrossRefGoogle Scholar
  8. 8.
    Hyman NH, Cataldo PA, Trevisani GT, Burns BH, Shackford SR. Tracking outcomes of anorectal surgery: the need for a disease-specific quality assessment tool. Dis Colon Rectum. 2008;51:1221–4.CrossRefGoogle Scholar
  9. 9.
    Ansell GL, Montgomery JE. Outcomes of ASA III patients undergoing day case surgery. Br J Anaesth. 2004;92(1):71–4.CrossRefGoogle Scholar
  10. 10.
    Joshi GP, Chung F, Vann MA, et al. Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg. 2010;111:L1378–87.CrossRefGoogle Scholar
  11. 11.
  12. 12.
    Albaladejo P, Marret E, Samama CM, et al. Non-cardiac surgery in patients with coronary stents: the RECO study. Heart. 2011;97:1566–72.CrossRefGoogle Scholar
  13. 13.
    Fujikawa T, Tanaka A, Abe T, et al. Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital. J Am Coll Surg. 2013;217(6):1044–53.CrossRefGoogle Scholar
  14. 14.
    Sahebally SM, Healy D, Coffey JC, Walsh SR. Should patients taking aspirin for secondary prevention continue or discontinue the medication prior to elective, abdominal surgery? Best evidence topic (BET). In J Surg. 2014;12(5):16–21.Google Scholar
  15. 15.
    Giannarini G, Mogorovich A, Valent F, et al. Continuing or discontinuing low-dose aspirin before transrectal prostate biopsy: results of a prospective randomized trial. Urology. 2007;70(3):501–5.CrossRefGoogle Scholar
  16. 16.
    Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth. 2010;104(3):305–12.CrossRefGoogle Scholar
  17. 17.
    Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med. 2005;257:399–414.CrossRefGoogle Scholar
  18. 18.
    Gerstein NS, Schulman PM, Gerstein WH, Petersen TR, Tawil I. Should more patients continue aspirin therapy perioperatively? Clinical impact of aspirin withdrawal syndrome. Ann Surg. 2012;255:811–9.CrossRefGoogle Scholar
  19. 19.
    Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494–503.CrossRefGoogle Scholar
  20. 20.
    Bailey HR, Snyder MJ. Selection, preoperative assessment, and education of the patient for ambulatory surgery. In:Ambulatory anorectal surgery. New York: Springer; 2000. p. 37–45.CrossRefGoogle Scholar
  21. 21.
    Beck DE, Wexner SD. Preoperative and postoperative management. In: Fundamentals of anorectal surgery. 2nd ed. New York: McGraw-Hill;1992; 50–56.Google Scholar
  22. 22.
    Bonardi RA, Rosin JD, Stonesifer GL Jr, Bauer FW. Bacteremias associated with routine hemorrhoidectomies. Dis Colon Rectum. 1976;19:233–6.CrossRefGoogle Scholar
  23. 23.
    Adami B, Eckardt VF, Suermann RB, Karbach U, Ewe K. Bacteremia after proctoscopy and hemorrhoidal injection sclerotherapy. Dis Colon Rectum. 1981;24:373–4.CrossRefGoogle Scholar
  24. 24.
    Nelson DW, Champagne BJ, Rivadeneira DE, et al. Prophylactic antibiotics for hemorrhoidectomy: are they really needed? Dis Colon Rectum. 2014;57:365–9.CrossRefGoogle Scholar
  25. 25.
    Khan KI, Akmal M, Wagas A, Mahmood S. Role of prophylactic antibiotics in Milligan Morgan hemorrhoidectomy—a randomized control trial. Int J Surg. 2014;12(8):868–71.CrossRefGoogle Scholar
  26. 26.
    Pannucci CJ, Shanks A, Moote MJ, et al. Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery. Ann Surg. 2012;255(6):1093–9.CrossRefGoogle Scholar
  27. 27.
    Petros JG, Bradley TM. Factors influencing postoperative urinary retention in patients undergoing surgery for benign anorectal disease. Am J Surg. 1990;159:374–6.CrossRefGoogle Scholar
  28. 28.
    Prasad ML, Abcarian H. Urinary retention following operations for benign anorectal diseases. Dis Colon Rectum. 1978;21:490–2.CrossRefGoogle Scholar
  29. 29.
    Zaheer S, Reilly WT, Pemberton JH, Ilstrup D. Urinary retention after operations for benign anorectal diseases. Dis Colon Rectum. 1998;41:696–704.CrossRefGoogle Scholar
  30. 30.
    Bailey HR, Ferguson JA. Prevention of urinary retention by fluid restriction following anorectal operations. Dis Colon Rectum. 1976;19:250–2.CrossRefGoogle Scholar
  31. 31.
    Hoff SD, Bailey HR, Butts DR, et al. Ambulatory surgical hemorrhoidectomy—a solution to postoperative urinary retention? Dis Colon Rectum. 1994;37(12):1242–4.CrossRefGoogle Scholar
  32. 32.
    Sozener U, Gedik E, Kessaf Aslar A, et al. Does adjuvant antibiotic treatment after drainage of anorectal abscess prevent development of anal fistulas? A randomized, placebo-controlled, double- blind, multicenter study. Dis Colon Rectum. 2011;54(8):923–9.CrossRefGoogle Scholar
  33. 33.
    Carapeti EA, Kamm MA, McDonald PJ, Phillips RK. Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet. 1998;351:169–72.CrossRefGoogle Scholar
  34. 34.
    Balfour L, Stojkovic SG, Botterill ID, Burke DA, Finan PJ, Sagar PM. A randomized, double-blind trial of the effect of metronidazole on pain after closed hemorrhoidectomy. Dis Colon Rectum. 2002;45(9):1186–90.CrossRefGoogle Scholar
  35. 35.
    Hosseini SV, Sabet B, Nouri Amirkolaee M, Bolandparvaz S. A randomized clinical trial on the effect of oral metronidazole on wound healing and pain after anal sphincterotomy and fissurectomy. Arch Iran Med. 2008;11(5):550–2.PubMedGoogle Scholar
  36. 36.
  37. 37.
  38. 38.
    Gupta PJ. Effects of warm water sitz bath on symptoms in post-anal sphincterotomy in chronic anal fissure—a randomized and controlled study. World J Surg. 2007;31(7):1480–4.CrossRefGoogle Scholar
  39. 39.
    Gupta PJ. Warm sitz bath does not reduce symptoms in posthaemorrhoidectomy period: a randomized, controlled study. ANZ J Surg. 2008;78(5):398–401.CrossRefGoogle Scholar
  40. 40.
    Dodi G, Bogoni F, Infantino A, Pianon P, Mortellaro LM, Lise M. Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles. Dis Colon Rectum. 1986;29(4):248–51.CrossRefGoogle Scholar
  41. 41.
    Richman IM. Use of Toradol in anorectal surgery. Dis Colon Rectum. 1993;36(3):295–6.CrossRefGoogle Scholar
  42. 42.
    Place RJ, Coloma M, White PF, Huber PJ, Van Vlymen J, Simmang CL. Ketorolac improves recovery after outpatient anorectal surgery. Dis Colon Rectum. 2000;43(6):804–8.CrossRefGoogle Scholar
  43. 43.
    O’Donovan S, Ferrara A, Larach S, Williamson P. Intraoperative use of Toradol facilitates outpatient hemorrhoidectomy. Dis Colon Rectum. 1994;37(8):793–9.CrossRefGoogle Scholar
  44. 44.
    De Oliveira GS, Agarwal D, Benzon HT. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesth Analg. 2012;114(2):424–33.CrossRefGoogle Scholar
  45. 45.
    Nicholson TJ, Armstrong D. Topical metronidazole (10 percent) decreases posthemorrhoidectomy pain and improves healing. Dis Colon Rectum. 2004;47(5):711–6.CrossRefGoogle Scholar
  46. 46.
    Ala S, Saeedi M, Eshghi F, Mirzabeygi P. Topical metronidazole can reduce pain after surgery and pain on defecation in postoperative hemorrhoidectomy. Dis Colon Rectum. 2008;51(2):235–8.CrossRefGoogle Scholar
  47. 47.
    Gupta PJ, Heda PS, Kalaskar S, Tamaskar VP. Topical sucralfate decreases pain after hemorrhoidectomy and improves healing: a randomized, blinded, controlled study. Dis Colon Rectum. 2008;51(2):231–4.CrossRefGoogle Scholar
  48. 48.
    Gupta PJ, Heda PS, Shrirao SA, Kalaskar SS. Topical sucralfate treatment of anal fistulotomy wounds: a randomized placebo-controlled trial. Dis Colon Rectum. 2011;54(6):699–704.CrossRefGoogle Scholar
  49. 49.
    Ratnasingham K, Uzzaman M, Andreani SM, Light D, Patel B. Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing. Int J Surg. 2010;8(8):606–11.CrossRefGoogle Scholar
  50. 50.
    Silverman R, Bendick PJ, Wasvary HJ. A randomized, prospective, double-blind, placebo-controlled trial of the effect of a calcium channel blocker ointment on pain after hemorrhoidectomy. Dis Colon Rectum. 2005;48(10):1913–6.CrossRefGoogle Scholar
  51. 51.
    Faiz OD, Brown TJ, Colucci G, Grover M, Clark SK. Trends in colorectal day case surgery in NHS Trusts between 1998 and 2005. Color Dis. 2008;10:935–42.Google Scholar
  52. 52.
    Lohsiriwat D, Lohsiriwat V. Outpatient hemorrhoidectomy under perianal anesthetics infiltration. J Med Assoc Thail. 2005;88:1821–4.Google Scholar
  53. 53.
    Hidalgo Grau LA, Heredia Budó A, Llorca Cardeñosa S, et al. Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse. Color Dis. 2012;14:765–8.CrossRefGoogle Scholar
  54. 54.
    Chan PY, Lee MP, Cheung HY, Chung CC, Li MK. Unplanned admission after day-case haemorrhoidectomy: a retrospective study. Asian J Surg. 2010;33:203–7.CrossRefGoogle Scholar
  55. 55.
    Grucela A, Gurland B, Kiran RP. Functional outcomes and quality of life after anorectal surgery. Am Surg. 2012;78:952–6.PubMedGoogle Scholar
  56. 56.
    Stephenson SV. Ambulatory surgical centers. JAMA. 1985;253(3):342–3.CrossRefGoogle Scholar
  57. 57.
    Lacerda-Filho A, Cunha-Melo JR. Outpatient haemorrhoidectomy under local anaesthesia. Eur J Surg. 1997;163:935–40.PubMedGoogle Scholar
  58. 58.
    Tong D, Chung F, Wong D. Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology. 1997;87:856–64.CrossRefGoogle Scholar
  59. 59.
    Toyonaga T, Matsushima M, Sogawa N, et al. Postoperative urinary retention after surgery for benign anorectal disease: potential risk factors and strategy for prevention. Int J Color Dis. 2006;21(7):676–82.CrossRefGoogle Scholar
  60. 60.
    Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology. 2009;110(5):1139–57.CrossRefGoogle Scholar
  61. 61.
    MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum. 1995;38(7):687–94.CrossRefGoogle Scholar
  62. 62.
    Rosen L, Sipe P, Stasik JJ, Riether RD, Trimpi HD. Outcome of delayed hemorrhage following surgical hemorrhoidectomy. Dis Colon Rectum. 1993;36(8):743–6.CrossRefGoogle Scholar
  63. 63.
    Nisar PJ, Acheson AG, Neal KR, Scholefield JH. Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum. 2004;47(11):1837–45.CrossRefGoogle Scholar
  64. 64.
    Chen HH, Wang JY, Changchien CR, Yeh CY, Tsai WS, Tang R. Effective management of posthemorrhoidectomy secondary hemorrhage using rectal irrigation. Dis Colon Rectum. 2002;45(2):234–8.CrossRefGoogle Scholar
  65. 65.
    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36(1):77–97.CrossRefGoogle Scholar
  66. 66.
    Roig JV, Jordán J, García-Armengol J, Esclapez P, Solana A. Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery. Dis Colon Rectum. 2009;52(8):1462–9.CrossRefGoogle Scholar
  67. 67.
    Visscher AP, Schuur D, Roos R, Van der Mijnsbrugge GJ, Meijerink WJ, Felt-Bersma RJ. Long-term follow-up after surgery for simple and complex cryptoglandular fistulas: fecal incontinence and impact on quality of life. Dis Colon Rectum. 2015;58(5):533–9.CrossRefGoogle Scholar
  68. 68.
    Jordán J, Roig JV, García-Armengol J, García-Granero E, Solana A, Lledó S. Risk factors for recurrence and incontinence after anal fistula surgery. Color Dis. 2010;12(3):254–60.CrossRefGoogle Scholar
  69. 69.
    Oh C, Divino CM, Steinhagen RM. Anal fissure. 20-year experience. Dis Colon Rectum. 1995;38(4):378–82.CrossRefGoogle Scholar
  70. 70.
    García-Aguilar J, Belmonte Montes C, Perez JJ, Jensen L, Madoff RD, Wong WD. Incontinence after lateral internal sphincterotomy: anatomic and functional evaluation. Dis Colon Rectum. 1998;41(4):423–7.CrossRefGoogle Scholar
  71. 71.
    Altomare DF, Ratto C, Ganio E, Lolli P, Masin A, Villani RD. Long-term outcome of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum. 2009;52(1):11–7.CrossRefGoogle Scholar
  72. 72.
    Wexner SD, Coller JA, Devroede G, et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg. 2010;251(3):441–9.CrossRefGoogle Scholar
  73. 73.
    Glasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review. Dis Colon Rectum. 2012;55(4):482–90.CrossRefGoogle Scholar
  74. 74.
    Ron Y, Avni Y, Lukovetski A, et al. Botulinum toxin type-A in therapy of patients with anismus. Dis Colon Rectum. 2001;44(12):1821–6.CrossRefGoogle Scholar
  75. 75.
    Mari FS, Nigri G, Di Cesare T, et al. Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations? Dis Colon Rectum. 2014;57(5):658–62.CrossRefGoogle Scholar
  76. 76.
    Martellucci J, Naldini G, Del Popolo G, Carriero A. Sacral nerve modulation in the treatment of chronic pain after pelvic surgery. Color Dis. 2012;14(4):502–7.CrossRefGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Nebraska Medical CenterOmahaUSA

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